- Email: [email protected]
Central Pancreatectomy with Double Pancreaticojejunostomy
SURGEON AT WORK
Central Pancreatectomy with Double Pancreaticojejunostomy Masayuki Sho, MD, PhD, FACS, Takahiro Akahori, MD, PhD, Minako Nagai, MD, Sohei Satoi, MD, PhD, FACS, Hiroaki Yanagimoto, MD, PhD, Shoichi Kinoshita, MD, Tomohisa Yamamoto, MD, Naoya Ikeda, MD, PhD, FACS, A-Hon Kwon, MD, PhD, Yoshiyuki Nakajima, MD, PhD underwent CP with double pancreaticojejunostomy (CP-DPJ) as part of a collaborative study from 2 surgical centers.
Central pancreatectomy (CP) is one surgical option for several pancreatic neoplasms and lesions. Benign and low-grade malignant lesions located from the neck and proximal body of the pancreas are common indicators for CP. Central pancreatectomy allows the normal parenchyma and the spleen to be spared when compared with distal pancreatectomy (DP). Therefore, the long-term efficacy of maintaining the endocrine and exocrine functions of the pancreas and preserving the immunologic function of the spleen can be expected. Furthermore, compared with pancreatoduodenectomy, CP enables the maintenance of bile flow and continuity of the upper gastrointestinal tract. In fact, in recent years, published studies on CP have been increasing.1-3 To perform CP, surgeons must manage 2 cut surfaces of the remnant pancreas. In most cases, the proximal stump of the pancreas is closed by suturing or stapling.2 The distal stump is usually managed by pancreaticojejunostomy (PJ) or pancreaticoogastrostomy (PG).2 Pancreatic fistula (PF) can occur from either side of the remnant pancreas, although it is difficult to identify the exact source. As a result, a comparatively high rate of PF after CP has been reported.2-5 Furthermore, it has also been shown that some patients develop grade C fistula and require reoperation. The high rate of PF has been a major obstacle for CP to become a standard procedure because PF is associated with a high incidence of life-threatening complications including intra-abdominal abscess, postoperative hemorrhage, or sepsis. Here we report our surgical technique and present the perioperative results for our initial series of 25 patients who
METHODS Patients Twenty-five consecutive patients indicated for CP were enrolled in this study (KANAPS-04 project study). Patients underwent CP between 2011 and 2014 at Nara Medical University Hospital or Kansai Medical University Hospital. Clinicopathologic factors were retrospectively analyzed. Patients provided written informed consent before treatment according to the rules and regulations of each institution. Surgical procedure After incision of the superior and inferior margins of the pancreas, the segment harboring the lesion was mobilized. The pancreas was isolated at its superior margin from the common hepatic and splenic arteries, when necessary. After placing marginal stitches on the proximal side, the pancreas was transected above the portal vein using an ultrasonic dissector. The main pancreatic duct was cut using a scalpel for duct-to-mucosa anastomosis. Then the posterior surface of the pancreas was carefully dissected from the splenic vein while avoiding vessel injury. The distal side of the pancreas was then transected in the same fashion (Fig. 1, Video 1). The cut surfaces of both sides of the resected pancreas were evaluated by pathology to check the resection margins. After resection of the pancreatic parenchyma, end-to-side PJ by a Roux-en-Y limb for both pancreatic stumps was performed via a retrocolic route with an appropriate length of the first jejunal loop. The anastomosis was performed in a duct-tomucosa fashion using a running or interrupted single layer suture with 6-0 Prolene (polypropylene, Johnson and Johnson Co). In a seromuscular-parenchymal anastomosis, the interrupted stitches with 4-0 Prolene were placed in an end-to-side fashion so that the jejunal wall was tightly adherent to the pancreatic stump. The proximal PJ was performed first (Fig. 2, Video 2), then the
Disclosure Information: Nothing to disclose. Received March 26, 2015; Revised May 1, 2015; Accepted May 1, 2015. From the Departments of Surgery, Nara Medical University, Nara, Japan (Sho, Akahori, Nagai, Kinoshita, Nakajima); Kansai Medical University, Hirakata, Japan (Satoi, Yanagimoto, Yamamoto, Kwon); and Nara Prefecture Western Medical Center, Japan (Ikeda). Correspondence address: Masayuki Sho, MD, PhD, FACS, Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 6348522, Japan. email: [email protected]
ª 2015 by the American College of Surgeons Published by Elsevier Inc.
e15
http://dx.doi.org/10.1016/j.jamcollsurg.2015.05.004 ISSN 1072-7515/15
Sho et al
e16
Double Pancreaticojejunostomy
J Am Coll Surg
Abbreviations and Acronym
CP CP-DPJ DP PF PG PJ
¼ ¼ ¼ ¼ ¼ ¼
central pancreatectomy CP with double pancreaticojejunostomy distal pancreatectomy pancreatic fistula pancreaticoogastrostomy pancreaticojejunostomy
distal PJ was completed (Fig. 3, Video 3). The pancreatic tube stent was not usually used for the duct-to-mucosa anastomosis. The operation was concluded with construction of an end-to-side jejuno-jejunostomy with a double layer of absorbable stitches, approximately 40 cm distal to the pancreatic anastomosis. One 10-mm polyurethane drain (Argyle, Multi-Channel Drainage; Covidien Japan) was placed near the stump of the remnant pancreas or PJ. Two surgeons (MS and SS) performed the operations in this series. Definition of pancreatic fistula and complication The amylase level in drainage fluid was routinely measured. Pancreatic fistula was defined as any measurable drainage output from an intraoperatively placed drain, with an amylase content greater than 3 times the upper limit of the normal serum amylase level, according to the guidelines of the International Study Group of Pancreatic Fistula (ISGPF).6 The Clavien-Dindo classification was used to evaluate postoperative complications.7
RESULTS A total of 25 patients underwent CP-DPJ at 2 surgical centers (Table 1). There were 11 men and 14 women, with a median age of 64 years (range 18 to 80 years). The pathologic diagnosis was intraductal papillary mucinous neoplasm in 11, pancreatic neuroendocrine tumor in 3, serous cystic neoplasm in 3, chronic pancreatitis in 2, benign cyst in 2, and mucinous cystic adenoma, pancreatic intraepithelial neoplasia, solid pseudopapillary neoplasm, and pancreatic adenocarcinoma in 1 each. Twenty-three of 25 patients had a soft pancreas. The mean main pancreatic duct diameters at the proximal and distal pancreatic stump were 2.2 and 2.9 mm, respectively. In 5 patients, an internal pancreatic tube stent was placed at distal PJ site. All of those patients had a small main pancreatic duct, with a median size of 1 to 1.5 mm, in the soft pancreas. Median operative time was 229 minutes (range 161 to 313 minutes), and overall postoperative morbidity was 68%. Sixteen cases of PF were graded A in 14 (56%) patients and B in 2 (8%) patients. In 2 cases of grade B PF, both patients had
Figure 1. Pancreas dissection and transection completed by central pancreatectomy. The pancreas was transected with an ultrasonic dissector, and the main pancreatic duct was cut with a scalpel for duct-to-mucosa anastomosis.
peripancreatic fluid collection on CT without any sign of sepsis. The drains were repositioned under transillumination and finally removed on postoperative days 18 and 30, respectively. The patients were discharged home on postoperative days 23 and 38, respectively. In the other 2 patients who were clinically well with no peripancreatic fluid collection as well as no signs of infection, the operatively placed drain was replaced by a smaller one, under transillumination, as a routine management practice for amylase-rich fluid. They were defined as having grade A PF. These 4 patients were classified as having Clavien-
Figure 2. The proximal pancreatic remnant was first anastomosed with a Roux-en-Y limb. The anastomosis of the jejunal loop to the main pancreatic duct was performed in a duct-to-mucosa fashion. The seromuscular-parenchymal anastomosis of the jejunal loop and the pancreas stump was completed in end-to-side fashion.
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Table 1. Patient Characteristics, Surgical Outcomes, and Postoperative Complications Variables
Figure 3. Pancreaticojejunostomy at the distal pancreatic stump was subsequently performed with a 2-layer anastomosis in the same fashion as with the proximal stump.
Dindo grade IIIa complications. None of the patients developed grade C PF requiring reoperation. There were no operative or hospital deaths. Median hospital stay was 13 days (range 7 to 38 days), and median follow-up was 25.3 months (range 8.2 to 47.9 months). By the time of analysis, none of the patients had developed new onset diabetes mellitus.
DISCUSSION Central pancreatectomy potentially has a significant advantage in preserving the pancreatic parenchyma compared with pancreatoduodenectomy or distal pancreatectomy, although such advantages have not yet been firmly proven. To take such advantage, CP has now been widely considered as a surgical option for benign or low-grade malignancy of the pancreas. However, a recent large-scale study in a single center and a study of literature review have demonstrated the considerably high rate of PF after CP.2-5 Goudard and colleagues4 reported their 100 consecutive cases with CP. In their single center experience, they showed grade B/C PF in 44%, reoperation in 6%, and a median hospital stay of 25 days. A 3% mortality rate was also reported. A recent literature review has shown that 20% of patients developed grade B/C PF as defined by International Study Group of Pancreatic Fistula criteria, 4% needed reoperation, and 0.8% died.2 Another literature review also reported that 10.4% showed grade C PF and 7.7% had reoperation.3 In our first 25 consecutive patients with CP-DPJ, only 8% developed grade B PF. Furthermore, none of the patients showed grade C PF or required reoperation. Most importantly, there was no mortality. Compared with recently published data, our surgical
Background characteristics Sex, male:female Age, y, median (range) BMI, kg/m2, mean SD ASA score, 1/2/3 Preoperative albumin, g/dL, mean SD Disease, n (%) IPMN PNET SCN CP Benign cyst Others Tumor size, cm, mean SD Pancreatic texture, n (%) Soft Hard Main pancreatic duct, cm, mean SD Proximal Distal Outcomes of operation Operation time, min, mean SD Blood loss, min, mean SD Hospital stay, d, median (range) Time to drain removal, d, median (range) Postoperative complications Morbidity, n (%) Clavien-Dindo classification I II IIIa IIIbeV Pancreatic fistula, n (%) A B C Reoperation, n Mortality, n
Data
11:14 64 (18e80) 22.1 3.3 8/16/1 4.3 0.3 11 (44) 3 (12) 3 (12) 2 (8) 2 (8) 4 (16) 2.6 1.6 23 (92) 2 (8) 2.2 1.0 2.9 1.4 234 36 150 139 13 (7e38) 5 (3e30) 17 (68) 8 (32) 5 (20) 4 (16) 0 14 (56) 2 (8) 0 0 0
ASA, American Society of Anesthesiologists; CP, chronic pancreatitis; IPMN, intraductal papillary mucinous neoplasm; PNET, pancreatic neuroendocrine tumors; SCN, serous cystic neoplasm.
technique may have some advantages in postoperative morbidity. According to a literature review on CP, the distal stump was usually managed by PJ, followed by PG.2 In most patients, the proximal stump was closed by sutures, followed by stapling.2 At present, the most
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Double Pancreaticojejunostomy
appropriate closure technique for the pancreatic stump, especially for the proximal stump, remains controversial. In DP, stapler closure has recently become a standard technique for pancreatic stump closure. However, the multicenter randomized DISPACT trial found that stapler closure did not significantly reduce the incidence of PF after DP in comparison with hand-sewn closure.8 Several studies have demonstrated that PJ has a significant advantage in reducing PF in patients who have undergone DP.9-11 Our results in this study may corroborate these previous studies. Although a definitive conclusion cannot be reached from this preliminary study, there are possible mechanisms to reduce PF by CP-DPJ. First, pancreatic juice drainage from the main pancreatic duct through PJ may decompress the main pancreatic duct and reduce pancreatic juice leakage from the branch pancreatic duct. This is because PF from the proximal stump may be the increased resistance to the outflow of pancreatic juice toward the duodenum due to spasm of the sphincter of Oddi and increased pancreatic ductal back-pressure.12,13 However, a randomized controlled trial has reported that prophylactic transpapillary pancreatic stent for decompression of the pancreatic duct did not reduce PF after DP.14 Therefore, we expected that decompression of pancreatic ductal back-pressure by PJ might prevent leakage of pancreatic juice from the proximal pancreatic stump. Second, a seromuscular-parenchymal anastomosis in PJ may help to reduce PF through tight adherence to the pancreatic stump followed by adhesion. A randomized clinical trial has shown some impact on pancreas-related complications of covering the stapled pancreatic stump with a seromuscular patch.15 Furthermore, occupying the dead space with the jejunal loop after resection of the middle pancreas may also have a positive effect on PF. Some studies demonstrated the advantages of other techniques, including stapler closure or PG.16 However, those procedures may not be suitable in certain patients such as those with a thick pancreas or for obese patients.17,18 Furthermore, it seems difficult to secure both pancreatic stumps with PG. Therefore, double PJ may be a possible option to prevent PF from both pancreatic stumps in CP in high risk cases. Recently, minimal invasive surgery, such as laparoscopic or robotic surgery, has also been performed in CP.17-19 However, considerable complications were reported, even with such innovative surgical techniques and devices. Therefore, clinically relevant PF is still a major challenge in CP. The combined use of CP-DPJ with these newer techniques may overcome the problematic obstacle in performing CP.
CONCLUSIONS In conclusion, this technique offers a secure coverage technique for both proximal and distal pancreatic stumps in CP, which might be useful even for patients with a soft pancreas and a small main pancreatic duct. Additional studies incorporating more patients are warranted to confirm the effectiveness of this technique. Author Contributions Study conception and design: Sho, Akahori, Satoi, Yanagimoto, Ikeda Acquisition of data: Nagai, Kinoshita, Yamamoto Analysis and interpretation of data: Sho, Akahori, Satoi, Yanagimoto, Ikeda Drafting of manuscript: Sho Critical revision: Ikeda, Kwon, Nakajima REFERENCES 1. Iacono C, Ruzzenente A, Bortolasi L, et al. Central pancreatectomy: the Dagradi Serio Iacono operation. Evolution of a surgical technique from the pioneers to the robotic approach. World J Gastroenterol 2014;20:15674e15681. 2. Iacono C, Verlato G, Ruzzenente A, et al. Systematic review of central pancreatectomy and meta-analysis of central versus distal pancreatectomy. Br J Surg 2013;100:873e885. 3. Zhou YM, Zhang XF, Wu LP, et al. Pancreatic fistula after central pancreatectomy: case series and review of the literature. Hepatobiliary Pancreat Dis Int 2014;13:203e208. 4. Goudard Y, Gaujoux S, Dokmak S, et al. Reappraisal of central pancreatectomy a 12-year single-center experience. JAMA Surg 2014;149:356e363. 5. Crippa S, Bassi C, Warshaw AL, et al. Middle pancreatectomy: indications, short- and long-term operative outcomes. Ann Surg 2007;246:69e76. 6. Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005;138:8e13. 7. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205e213. 8. Diener MK, Seiler CM, Rossion I, et al. Efficacy of stapler versus hand-sewn closure after distal pancreatectomy (DISPACT): a randomised, controlled multicentre trial. Lancet 2011;377:1514e1522. 9. Kleeff J, Diener MK, Z’Graggen K, et al. Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases. Ann Surg 2007;245:573e582. 10. Wagner M, Gloor B, Ambuhl M, et al. Roux-en-Y drainage of the pancreatic stump decreases pancreatic fistula after distal pancreatic resection. J Gastrointest Surg 2007;11:303e308. 11. Meniconi RL, Caronna R, Borreca D, et al. Pancreato-jejunostomy versus hand-sewn closure of the pancreatic stump to prevent pancreatic fistula after distal pancreatectomy: a retrospective analysis. BMC Surg 2013;13:23. 12. Renou C, Grandval P, Ville E, et al. Endoscopic treatment of the main pancreatic duct: correlations among morphology, manometry, and clinical follow-up. Int J Pancreatol 2000; 27:143e149.
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13. Hashimoto Y, Traverso LW. After distal pancreatectomy pancreatic leakage from the stump of the pancreas may be due to drain failure or pancreatic ductal back pressure. J Gastrointest Surg 2012;16:993e1003. 14. Frozanpor F, Lundell L, Segersvard R, et al. The effect of prophylactic transpapillary pancreatic stent insertion on clinically significant leak rate following distal pancreatectomy: results of a prospective controlled clinical trial. Ann Surg 2012;255: 1032e1036. 15. Olah A, Issekutz A, Belagyi T, et al. Randomized clinical trial of techniques for closure of the pancreatic remnant following distal pancreatectomy. Br J Surg 2009;96:602e607.
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16. Goldstein MJ, Toman J, Chabot JA. Pancreaticogastrostomy: a novel application after central pancreatectomy. J Am Coll Surg 2004;198:871e876. 17. Kang CM, Lee JH, Lee WJ. Minimally invasive central pancreatectomy: current status and future directions. J Hepatobiliary Pancreat Sci 2014;21:831e840. 18. Song KB, Kim SC, Park KM, et al. Laparoscopic central pancreatectomy for benign or low-grade malignant lesions in the pancreatic neck and proximal body. Surg Endosc 2015; 29:937e946. 19. Zureikat AH, Moser AJ, Boone BA, et al. 250 robotic pancreatic resections: safety and feasibility. Ann Surg 2013;258:554e559.
Central Pancreatectomy with Double Pancreaticojejunostomy Masayuki Sho, MD, PhD, FACS, Takahiro Akahori, MD, PhD, Minako Nagai, MD, Sohei Satoi, MD, PhD, FACS, Hiroaki Yanagimoto, MD, PhD, Shoichi Kinoshita, MD, Tomohisa Yamamoto, MD, Naoya Ikeda, MD, PhD, FACS, A-Hon Kwon, MD, PhD, Yoshiyuki Nakajima, MD, PhD underwent CP with double pancreaticojejunostomy (CP-DPJ) as part of a collaborative study from 2 surgical centers.
Central pancreatectomy (CP) is one surgical option for several pancreatic neoplasms and lesions. Benign and low-grade malignant lesions located from the neck and proximal body of the pancreas are common indicators for CP. Central pancreatectomy allows the normal parenchyma and the spleen to be spared when compared with distal pancreatectomy (DP). Therefore, the long-term efficacy of maintaining the endocrine and exocrine functions of the pancreas and preserving the immunologic function of the spleen can be expected. Furthermore, compared with pancreatoduodenectomy, CP enables the maintenance of bile flow and continuity of the upper gastrointestinal tract. In fact, in recent years, published studies on CP have been increasing.1-3 To perform CP, surgeons must manage 2 cut surfaces of the remnant pancreas. In most cases, the proximal stump of the pancreas is closed by suturing or stapling.2 The distal stump is usually managed by pancreaticojejunostomy (PJ) or pancreaticoogastrostomy (PG).2 Pancreatic fistula (PF) can occur from either side of the remnant pancreas, although it is difficult to identify the exact source. As a result, a comparatively high rate of PF after CP has been reported.2-5 Furthermore, it has also been shown that some patients develop grade C fistula and require reoperation. The high rate of PF has been a major obstacle for CP to become a standard procedure because PF is associated with a high incidence of life-threatening complications including intra-abdominal abscess, postoperative hemorrhage, or sepsis. Here we report our surgical technique and present the perioperative results for our initial series of 25 patients who
METHODS Patients Twenty-five consecutive patients indicated for CP were enrolled in this study (KANAPS-04 project study). Patients underwent CP between 2011 and 2014 at Nara Medical University Hospital or Kansai Medical University Hospital. Clinicopathologic factors were retrospectively analyzed. Patients provided written informed consent before treatment according to the rules and regulations of each institution. Surgical procedure After incision of the superior and inferior margins of the pancreas, the segment harboring the lesion was mobilized. The pancreas was isolated at its superior margin from the common hepatic and splenic arteries, when necessary. After placing marginal stitches on the proximal side, the pancreas was transected above the portal vein using an ultrasonic dissector. The main pancreatic duct was cut using a scalpel for duct-to-mucosa anastomosis. Then the posterior surface of the pancreas was carefully dissected from the splenic vein while avoiding vessel injury. The distal side of the pancreas was then transected in the same fashion (Fig. 1, Video 1). The cut surfaces of both sides of the resected pancreas were evaluated by pathology to check the resection margins. After resection of the pancreatic parenchyma, end-to-side PJ by a Roux-en-Y limb for both pancreatic stumps was performed via a retrocolic route with an appropriate length of the first jejunal loop. The anastomosis was performed in a duct-tomucosa fashion using a running or interrupted single layer suture with 6-0 Prolene (polypropylene, Johnson and Johnson Co). In a seromuscular-parenchymal anastomosis, the interrupted stitches with 4-0 Prolene were placed in an end-to-side fashion so that the jejunal wall was tightly adherent to the pancreatic stump. The proximal PJ was performed first (Fig. 2, Video 2), then the
Disclosure Information: Nothing to disclose. Received March 26, 2015; Revised May 1, 2015; Accepted May 1, 2015. From the Departments of Surgery, Nara Medical University, Nara, Japan (Sho, Akahori, Nagai, Kinoshita, Nakajima); Kansai Medical University, Hirakata, Japan (Satoi, Yanagimoto, Yamamoto, Kwon); and Nara Prefecture Western Medical Center, Japan (Ikeda). Correspondence address: Masayuki Sho, MD, PhD, FACS, Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 6348522, Japan. email: [email protected]
ª 2015 by the American College of Surgeons Published by Elsevier Inc.
e15
http://dx.doi.org/10.1016/j.jamcollsurg.2015.05.004 ISSN 1072-7515/15
Sho et al
e16
Double Pancreaticojejunostomy
J Am Coll Surg
Abbreviations and Acronym
CP CP-DPJ DP PF PG PJ
¼ ¼ ¼ ¼ ¼ ¼
central pancreatectomy CP with double pancreaticojejunostomy distal pancreatectomy pancreatic fistula pancreaticoogastrostomy pancreaticojejunostomy
distal PJ was completed (Fig. 3, Video 3). The pancreatic tube stent was not usually used for the duct-to-mucosa anastomosis. The operation was concluded with construction of an end-to-side jejuno-jejunostomy with a double layer of absorbable stitches, approximately 40 cm distal to the pancreatic anastomosis. One 10-mm polyurethane drain (Argyle, Multi-Channel Drainage; Covidien Japan) was placed near the stump of the remnant pancreas or PJ. Two surgeons (MS and SS) performed the operations in this series. Definition of pancreatic fistula and complication The amylase level in drainage fluid was routinely measured. Pancreatic fistula was defined as any measurable drainage output from an intraoperatively placed drain, with an amylase content greater than 3 times the upper limit of the normal serum amylase level, according to the guidelines of the International Study Group of Pancreatic Fistula (ISGPF).6 The Clavien-Dindo classification was used to evaluate postoperative complications.7
RESULTS A total of 25 patients underwent CP-DPJ at 2 surgical centers (Table 1). There were 11 men and 14 women, with a median age of 64 years (range 18 to 80 years). The pathologic diagnosis was intraductal papillary mucinous neoplasm in 11, pancreatic neuroendocrine tumor in 3, serous cystic neoplasm in 3, chronic pancreatitis in 2, benign cyst in 2, and mucinous cystic adenoma, pancreatic intraepithelial neoplasia, solid pseudopapillary neoplasm, and pancreatic adenocarcinoma in 1 each. Twenty-three of 25 patients had a soft pancreas. The mean main pancreatic duct diameters at the proximal and distal pancreatic stump were 2.2 and 2.9 mm, respectively. In 5 patients, an internal pancreatic tube stent was placed at distal PJ site. All of those patients had a small main pancreatic duct, with a median size of 1 to 1.5 mm, in the soft pancreas. Median operative time was 229 minutes (range 161 to 313 minutes), and overall postoperative morbidity was 68%. Sixteen cases of PF were graded A in 14 (56%) patients and B in 2 (8%) patients. In 2 cases of grade B PF, both patients had
Figure 1. Pancreas dissection and transection completed by central pancreatectomy. The pancreas was transected with an ultrasonic dissector, and the main pancreatic duct was cut with a scalpel for duct-to-mucosa anastomosis.
peripancreatic fluid collection on CT without any sign of sepsis. The drains were repositioned under transillumination and finally removed on postoperative days 18 and 30, respectively. The patients were discharged home on postoperative days 23 and 38, respectively. In the other 2 patients who were clinically well with no peripancreatic fluid collection as well as no signs of infection, the operatively placed drain was replaced by a smaller one, under transillumination, as a routine management practice for amylase-rich fluid. They were defined as having grade A PF. These 4 patients were classified as having Clavien-
Figure 2. The proximal pancreatic remnant was first anastomosed with a Roux-en-Y limb. The anastomosis of the jejunal loop to the main pancreatic duct was performed in a duct-to-mucosa fashion. The seromuscular-parenchymal anastomosis of the jejunal loop and the pancreas stump was completed in end-to-side fashion.
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Double Pancreaticojejunostomy
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Table 1. Patient Characteristics, Surgical Outcomes, and Postoperative Complications Variables
Figure 3. Pancreaticojejunostomy at the distal pancreatic stump was subsequently performed with a 2-layer anastomosis in the same fashion as with the proximal stump.
Dindo grade IIIa complications. None of the patients developed grade C PF requiring reoperation. There were no operative or hospital deaths. Median hospital stay was 13 days (range 7 to 38 days), and median follow-up was 25.3 months (range 8.2 to 47.9 months). By the time of analysis, none of the patients had developed new onset diabetes mellitus.
DISCUSSION Central pancreatectomy potentially has a significant advantage in preserving the pancreatic parenchyma compared with pancreatoduodenectomy or distal pancreatectomy, although such advantages have not yet been firmly proven. To take such advantage, CP has now been widely considered as a surgical option for benign or low-grade malignancy of the pancreas. However, a recent large-scale study in a single center and a study of literature review have demonstrated the considerably high rate of PF after CP.2-5 Goudard and colleagues4 reported their 100 consecutive cases with CP. In their single center experience, they showed grade B/C PF in 44%, reoperation in 6%, and a median hospital stay of 25 days. A 3% mortality rate was also reported. A recent literature review has shown that 20% of patients developed grade B/C PF as defined by International Study Group of Pancreatic Fistula criteria, 4% needed reoperation, and 0.8% died.2 Another literature review also reported that 10.4% showed grade C PF and 7.7% had reoperation.3 In our first 25 consecutive patients with CP-DPJ, only 8% developed grade B PF. Furthermore, none of the patients showed grade C PF or required reoperation. Most importantly, there was no mortality. Compared with recently published data, our surgical
Background characteristics Sex, male:female Age, y, median (range) BMI, kg/m2, mean SD ASA score, 1/2/3 Preoperative albumin, g/dL, mean SD Disease, n (%) IPMN PNET SCN CP Benign cyst Others Tumor size, cm, mean SD Pancreatic texture, n (%) Soft Hard Main pancreatic duct, cm, mean SD Proximal Distal Outcomes of operation Operation time, min, mean SD Blood loss, min, mean SD Hospital stay, d, median (range) Time to drain removal, d, median (range) Postoperative complications Morbidity, n (%) Clavien-Dindo classification I II IIIa IIIbeV Pancreatic fistula, n (%) A B C Reoperation, n Mortality, n
Data
11:14 64 (18e80) 22.1 3.3 8/16/1 4.3 0.3 11 (44) 3 (12) 3 (12) 2 (8) 2 (8) 4 (16) 2.6 1.6 23 (92) 2 (8) 2.2 1.0 2.9 1.4 234 36 150 139 13 (7e38) 5 (3e30) 17 (68) 8 (32) 5 (20) 4 (16) 0 14 (56) 2 (8) 0 0 0
ASA, American Society of Anesthesiologists; CP, chronic pancreatitis; IPMN, intraductal papillary mucinous neoplasm; PNET, pancreatic neuroendocrine tumors; SCN, serous cystic neoplasm.
technique may have some advantages in postoperative morbidity. According to a literature review on CP, the distal stump was usually managed by PJ, followed by PG.2 In most patients, the proximal stump was closed by sutures, followed by stapling.2 At present, the most
e18
Sho et al
J Am Coll Surg
Double Pancreaticojejunostomy
appropriate closure technique for the pancreatic stump, especially for the proximal stump, remains controversial. In DP, stapler closure has recently become a standard technique for pancreatic stump closure. However, the multicenter randomized DISPACT trial found that stapler closure did not significantly reduce the incidence of PF after DP in comparison with hand-sewn closure.8 Several studies have demonstrated that PJ has a significant advantage in reducing PF in patients who have undergone DP.9-11 Our results in this study may corroborate these previous studies. Although a definitive conclusion cannot be reached from this preliminary study, there are possible mechanisms to reduce PF by CP-DPJ. First, pancreatic juice drainage from the main pancreatic duct through PJ may decompress the main pancreatic duct and reduce pancreatic juice leakage from the branch pancreatic duct. This is because PF from the proximal stump may be the increased resistance to the outflow of pancreatic juice toward the duodenum due to spasm of the sphincter of Oddi and increased pancreatic ductal back-pressure.12,13 However, a randomized controlled trial has reported that prophylactic transpapillary pancreatic stent for decompression of the pancreatic duct did not reduce PF after DP.14 Therefore, we expected that decompression of pancreatic ductal back-pressure by PJ might prevent leakage of pancreatic juice from the proximal pancreatic stump. Second, a seromuscular-parenchymal anastomosis in PJ may help to reduce PF through tight adherence to the pancreatic stump followed by adhesion. A randomized clinical trial has shown some impact on pancreas-related complications of covering the stapled pancreatic stump with a seromuscular patch.15 Furthermore, occupying the dead space with the jejunal loop after resection of the middle pancreas may also have a positive effect on PF. Some studies demonstrated the advantages of other techniques, including stapler closure or PG.16 However, those procedures may not be suitable in certain patients such as those with a thick pancreas or for obese patients.17,18 Furthermore, it seems difficult to secure both pancreatic stumps with PG. Therefore, double PJ may be a possible option to prevent PF from both pancreatic stumps in CP in high risk cases. Recently, minimal invasive surgery, such as laparoscopic or robotic surgery, has also been performed in CP.17-19 However, considerable complications were reported, even with such innovative surgical techniques and devices. Therefore, clinically relevant PF is still a major challenge in CP. The combined use of CP-DPJ with these newer techniques may overcome the problematic obstacle in performing CP.
CONCLUSIONS In conclusion, this technique offers a secure coverage technique for both proximal and distal pancreatic stumps in CP, which might be useful even for patients with a soft pancreas and a small main pancreatic duct. Additional studies incorporating more patients are warranted to confirm the effectiveness of this technique. Author Contributions Study conception and design: Sho, Akahori, Satoi, Yanagimoto, Ikeda Acquisition of data: Nagai, Kinoshita, Yamamoto Analysis and interpretation of data: Sho, Akahori, Satoi, Yanagimoto, Ikeda Drafting of manuscript: Sho Critical revision: Ikeda, Kwon, Nakajima REFERENCES 1. Iacono C, Ruzzenente A, Bortolasi L, et al. Central pancreatectomy: the Dagradi Serio Iacono operation. Evolution of a surgical technique from the pioneers to the robotic approach. World J Gastroenterol 2014;20:15674e15681. 2. Iacono C, Verlato G, Ruzzenente A, et al. Systematic review of central pancreatectomy and meta-analysis of central versus distal pancreatectomy. Br J Surg 2013;100:873e885. 3. Zhou YM, Zhang XF, Wu LP, et al. Pancreatic fistula after central pancreatectomy: case series and review of the literature. Hepatobiliary Pancreat Dis Int 2014;13:203e208. 4. Goudard Y, Gaujoux S, Dokmak S, et al. Reappraisal of central pancreatectomy a 12-year single-center experience. JAMA Surg 2014;149:356e363. 5. Crippa S, Bassi C, Warshaw AL, et al. Middle pancreatectomy: indications, short- and long-term operative outcomes. Ann Surg 2007;246:69e76. 6. Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005;138:8e13. 7. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205e213. 8. Diener MK, Seiler CM, Rossion I, et al. Efficacy of stapler versus hand-sewn closure after distal pancreatectomy (DISPACT): a randomised, controlled multicentre trial. Lancet 2011;377:1514e1522. 9. Kleeff J, Diener MK, Z’Graggen K, et al. Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases. Ann Surg 2007;245:573e582. 10. Wagner M, Gloor B, Ambuhl M, et al. Roux-en-Y drainage of the pancreatic stump decreases pancreatic fistula after distal pancreatic resection. J Gastrointest Surg 2007;11:303e308. 11. Meniconi RL, Caronna R, Borreca D, et al. Pancreato-jejunostomy versus hand-sewn closure of the pancreatic stump to prevent pancreatic fistula after distal pancreatectomy: a retrospective analysis. BMC Surg 2013;13:23. 12. Renou C, Grandval P, Ville E, et al. Endoscopic treatment of the main pancreatic duct: correlations among morphology, manometry, and clinical follow-up. Int J Pancreatol 2000; 27:143e149.
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13. Hashimoto Y, Traverso LW. After distal pancreatectomy pancreatic leakage from the stump of the pancreas may be due to drain failure or pancreatic ductal back pressure. J Gastrointest Surg 2012;16:993e1003. 14. Frozanpor F, Lundell L, Segersvard R, et al. The effect of prophylactic transpapillary pancreatic stent insertion on clinically significant leak rate following distal pancreatectomy: results of a prospective controlled clinical trial. Ann Surg 2012;255: 1032e1036. 15. Olah A, Issekutz A, Belagyi T, et al. Randomized clinical trial of techniques for closure of the pancreatic remnant following distal pancreatectomy. Br J Surg 2009;96:602e607.
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16. Goldstein MJ, Toman J, Chabot JA. Pancreaticogastrostomy: a novel application after central pancreatectomy. J Am Coll Surg 2004;198:871e876. 17. Kang CM, Lee JH, Lee WJ. Minimally invasive central pancreatectomy: current status and future directions. J Hepatobiliary Pancreat Sci 2014;21:831e840. 18. Song KB, Kim SC, Park KM, et al. Laparoscopic central pancreatectomy for benign or low-grade malignant lesions in the pancreatic neck and proximal body. Surg Endosc 2015; 29:937e946. 19. Zureikat AH, Moser AJ, Boone BA, et al. 250 robotic pancreatic resections: safety and feasibility. Ann Surg 2013;258:554e559.